Facility Evaluation Report

LPA Marrufo conducted an unannounced Case Management Visit and met with Administrator (ADM) Rey Mirelez.

The purpose of the visit was to issue an Advisory Note based on findings discovered during a complaint investigation received on 07/09/2024. During interview on 09/26/2025, staff S1 stated to have written the wrong start date on R1's Centrally Stored Medication and Destruction Record.

During interview on 10/10/2025, ADM stated that the facility policy regarding when a parent of a client picks up unused medications is that the staff responsible for the medications will review the medication count with the parent and sign out the medications.

During visit on 07/22/2025, LPA Marrufo obtained a copy of R1’s CSMDR from March 2024. The CSMDR had a handwritten note that stated that on 03/25/2024, R1’s parent retrieved 260 capsules of M1 and left the facility with a balance of 168 capsules of M1.

During visit on 10/10/2025, LPA Marrufo reviewed R1’s medication record and did not find a sign-out sheet for the capsules of M1 that were stated to have been retrieved by R1’s parent on the March CSMDR.

An Advisory Note was issued. See LIC9102 page for more information. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with ADM Rey Mirelez and a copy of this report was provided.